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Pharmacy

HNE Formulary: Limitations - Step Therapy

The formulary list was last updated on 09/01/07, please be advised the information listed may not reflect the most current data and may be updated at any time without notice.

Please call HNE Member Services at (413) 787-4000 or
(800) 310-2835 for assistance.

Step Therapy

Step therapy is an approach to medication management. Step Therapy is a program designed exclusively for people who have certain conditions—arthritis, high blood pressure, and high cholesterol, for example — that require them to take medications regularly. The HNE Step Therapy program is all about value — about getting the most for your money. Most simply, that means getting a tried-and-true medication that’s proven safe and effective for your condition, and getting it at the lowest possible cost.

This program is designed to have your prescription drugs be more affordable. We will work with you and your physician to be certain that you are getting the appropriate drug for your condition. Claims for drugs listed in the first column below will process only if you have had a prescription filled of at least one of the first line medications listed in the third column within the last 180 days.

If you have any questions about the program or need any pharmacy forms, please contact our Member Services Department at 1-800-310-2835 or 413-787-4004, or visit our website at hne.com .

Please note: The use of samples does not satisfy the requirements of documented usage of a First Line drug of medical necessity for a Step Therapy drug. If it is medically necessary for you to use a Step Therapy drug before trying a First Line drug, then your doctor can contact HNE to request a Pharmacy review.

Only FDA maintenance indicator drugs are allowed through mail order.

Step Therapy Drug	Indications	First Line protocol (no form required)	Process when protocol is not met
Angiotensin II Receptor Antagonist Blocker (ARB) Atacand Atacand HCT Avapro Avalide Benicar Benicar HCT Cozaar Diovan Diovan HCT Exforge Hyzaar Micardis Micardis HCT Teveten Teveten HCT	Hypertension Nephropathy in type 2 diabetes Reduce stroke risk Heart failure Post- MI	Must have tried and failed at least one of the following generic drugs within the previous 180 days: Benazepril hydrochloride Benazepril/hydrochlorothiazide Captopril Captopril/hydrochlorothiazide Enalapril maleate Enalapril/hydrochlorothiazide Fosinopril sodium Fosinopril/hydrochlorothiazide Lisinopril Lisinopril/hydrochlorothiazide Moexipril hydrochloride Moexipril/hydrochlorothiazide Quinapril hydrochloride Quinapril/hydrochlorothiazide Trandolapril	PA form to be submitted by the requesting physician. (specific medical necessity form available for the ARB)
Anti-depressants: Cymbalta, Effexor XR, Lexapro, Paxil CR, Pexeva, Prozac weekly, Wellbutrin XL,	Depression	Must have tried and failed at least one of the following generic drugs within the previous 180 days: budeprion, bupropion, citalopram HBR, fluoxetine HCL, fluvoxamine maleate, mirtazapine, paroxetine HCL, sertraline, venlafaxine HCL. Does not exceed quantity limit (please reference quantity limitation list) Does not apply members who are 18 and under.	Medication Review form must be submitted by the requesting physician.
Cardiovascular Medications: Advicor, Altoprev, Caduet, Crestor, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Pravigard, Vytorin, Zocor	Hypercholesterolemia	Must have tried and failed at least one of the following generic drugs within the previous 180 days: lovastatin pravastatin simvastatin. Does not exceed quantity limit (please reference quantity limitation list)	Medication Review form must be submitted by the requesting physician.
Constipation: Amitiza	Constipation	Must have tried and failed the following generic drug within the previous 180 days lactulose Does not exceed quantity limit (please reference quantity limitation list)	Medication Review form must be submitted by the requesting physician.
Overactive Bladder: Detrol Detrol LA Ditropan Ditropan XL Enablex Sanctura Vesicare	Overactive bladder	Must have tried and failed one of the following generic drugs within the previous 180 days oxybutynin oxybutynin XL	Medication Review form must be submitted by the requesting physician
Proton Pump Inhibitors: Aciphex, Nexium, Prevacid, Prilosec, Protonix, Zegerid	Gastroesophageal reflux (GERD) Erosive esophagitis Pathologic hypersecretory	Must have tried and failed at least one of the following generic drugs within the previous 180 days: omeprazole, Prilosec 20mg OTC. Does not exceed quantity limit (please reference quantity limitation list) Does not apply to members who are 18 & under	Medication Review form must be submitted by the requesting physician.
Arava	Rheumatoid Arthritis	Must have filled at least one prescription written by an In-Plan Rheumatologist within a 12 month period.	PA form must be submitted by requesting physician.
Bravellle Follistim	Infertility	Must have an approved infertility cycle Must have tried and failed Gonal-F	Medical Necessity PA form to be submitted by requesting physician
Celebrex	Rheumatoid Arthritis Osteoarthritis Acute Pain	Age greater than 60 or Within the past 180 days filled prescription for at least 2 different anti- inflammatory drugs Filled one prescription for an oral corticosteroid Filled one prescription for a anticoagulant or antiplatelet agent within the previous 90 days. Does not exceed quantity limit ( please reference quantity limitation list)	PA form must be submitted by requesting physician
Emend	Nausea and vomiting associated with chemotherapy	Prescription is written by an In-Plan Oncologist/ Hematologist or All other specialties: Does not exceed quantity limit ( please reference quantity limitation list)	Medication Review form must be submitted by the requesting physician.
Enbrel Please Note:	Rheumatoid Arthritis For the diagnosis of psoriasis prior authorization is required and step therapy does not apply.	Must have filled at least one prescription written by an In-Plan Rheumatologist within a 12 month period. Does not exceed quantity limit (please reference quantity limitation list)	PA form must be submitted by requesting physician
Humira	Rheumatoid Arthritis the diagnosis of Crohn's Disease	Must have tried and failed at least one prescription written by an In-Plan Rheumatologist within a 12 month period. Does not exceed quantity limit (please reference quantity limitation list)	PA form must be submitted by requesting physician
Kineret	Rheumatoid Arthritis	Must have filled at least one prescription written by an In-Plan Rheumatologist within a 12 month period.	PA form must be submitted by requesting physician
Lyrica	Diabetic Neuropathy	Must have filled at least one prescription, for one of the following or a combination of within the previous 180 day Carbamazepine, Depakote, Dilantin, Felbatol, Gabitril, Gabapentin, Lamictal, Keppra, Neurontin, Tegretol, Topamax, Zonegran	Medication Review form must be submitted by the requesting physician
Mobic (meloxicam)	Osteoarthritis Arthritis	Age greater than 60 or Within the past 180 days filled prescription for at least 2 different anti- inflammatory drugs Filled one prescription for an oral corticosteroid Filled one prescription for an anticoagulant or antiplatelet agent within the previous 90 days. Does not exceed quantity limit (please reference quantity limitation list)	PA form must be submitted by requesting physician
Singulair	Asthma	Must have filled at least one prescription within the previous 180 days used for the treatment of Asthma.	PA form must be submitted by requesting physician
Vfend	Antifungal	Prescription is written by an In-Plan Oncologist/ Hematologist or Infectious Disease.	PA form must be submitted by requesting physician

Self-Administered Injectable Medications
Some injectable medications may be injected by properly trained medical staff only. These medications are covered in full when provided during a Covered Service. Other injectable medications are available at retail pharmacies, and may be self administered, that is, injected by the patient him- or herself. These medications are covered under HNE's pharmacy benefit even if injected by an In-Plan Provider. If your pharmacy coverage is not provided by HNE, HNE will not cover injectable drugs that may be self administered. For a list of self-administered injectable medications, please contact HNE Member Services.

If you so choose to send your prescriptions, you can take advantage of a $0 copay for all specialty injectable medications (A deductible may apply if you have a prescription benefit that has a yearly deductible).

Curascript’s order forms are available on our Web site or can be faxed to your provider by calling Health New England’s Member Services Department at 1-800-310-2835.

Please note:
Attention Deficit Disorder Medications that are classified as a controlled substance (CII & CIII): can now be filled for up to a 60 day supply at an In-Plan Retail Pharmacy (this is subject to the stores internal policy). One co-payment applies for each 30-day supply. This applies to the state of Massachusetts pharmacies only. All other states are subject to their own state laws and internal store policies.

Note: This list is subject to change.